Clinical UM Guideline |
Subject: Colonoscopy | |
Guideline #: CG-SURG-01 | Publish Date: 09/27/2023 |
Status: Revised | Last Review Date: 08/10/2023 |
Description |
This document addresses colonoscopy, an endoscopic procedure which allows direct visual inspection of the entire colon and rectum. Additionally, biopsy or excision of polyps or other abnormalities are possible during the colonoscopy procedure.
Colonoscopy must be distinguished from CT colonography, an imaging procedure that provides indirect visualization of the colon and rectum using CT scans. This document does not address CT Colonography.
Clinical Indications |
Note: The parenthetical numbers in the Clinical Indications section refer to the source documents cited in the References section below.
Medically Necessary:
Not Medically Necessary:
Other indications for screening or surveillance colonoscopy, not listed above, are considered not medically necessary.
Diagnostic Colonoscopy
Medically Necessary:
Not Medically Necessary:
Therapeutic Colonoscopy
Medically Necessary:
Not Medically Necessary:
Other indications for therapeutic colonoscopy, not listed above are considered not medically necessary.
Coding |
The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
When services may be Medically Necessary when criteria are met:
CPT |
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44388 | Colonoscopy through stoma; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) |
44389 | Colonoscopy through stoma; with biopsy, single or multiple |
44390 | Colonoscopy through stoma; with removal of foreign body(s) |
44391 | Colonoscopy through stoma; with control of bleeding, any method |
44392 | Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps |
44394 | Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique |
44401 | Colonoscopy through stoma; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre-and post-dilation and guide wire passage, when performed) |
44402 | Colonoscopy through stoma; with endoscopic stent placement (including pre- and post-dilation and guide wire passage, when performed) |
44403 | Colonoscopy through stoma; with endoscopic mucosal resection |
44404 | Colonoscopy through stoma; with directed submucosal injection(s), any substance |
44405 | Colonoscopy through stoma; with transendoscopic balloon dilation |
45378 | Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) |
45379 | Colonoscopy, flexible; with removal of foreign body(s) |
45380 | Colonoscopy, flexible; with biopsy, single or multiple |
45381 | Colonoscopy, flexible; with directed submucosal injection(s), any substance |
45382 | Colonoscopy, flexible; with control of bleeding, any method |
45384 | Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps |
45385 | Colonoscopy, flexible; with removal of tumor(s), polyps(s), or other lesion(s) by snare technique |
45386 | Colonoscopy, flexible; with transendoscopic balloon dilation |
45388 | Colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed) |
45389 | Colonoscopy, flexible; with endoscopic stent placement (includes pre- and post-dilation and guide wire passage, when performed) |
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HCPCS |
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G0105 | Colorectal cancer screening; colonoscopy on individual at high risk |
G0121 | Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk |
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ICD-10 Diagnosis |
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All diagnoses |
When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met or for situations designated in the Clinical Indications section as not medically necessary.
Discussion/General Information |
Screening, surveillance and diagnostic indications for colonoscopy are based on guidelines from a variety of specialty societies and government organizations. The source for each of the indications listed above is indicated by the referenced citation.
Generally speaking, screening refers to an effort or program which is used to detect a condition in an asymptomatic individual so that early detection and treatment can be provided for those who test positive for the condition. Surveillance refers to the systematic identification and evaluation of individuals considered to be at increased risk for the occurrence or recurrence of a condition or disease (for example; colorectal cancer or adenomatous polyps. Diagnostic testing is typically done to confirm or rule out a condition in an individual who is symptomatic or who, for some other reason, is believed to have a specific condition.
Several organizations have published recommendations for colorectal cancer screening and provided guidance on when colorectal cancer screening should be initiated. The U.S. Multi-Society Task Force of Colorectal Cancer (USMSTF), which represents the American College of Gastroenterology, the American Gastroenterological Association, and The American Society for Gastrointestinal Endoscopy recommends that African Americans at average risk for colorectal cancer begin screening at 45 years of age because of an increased incidence of colorectal cancer in this population (Rex, 2018). The collaborative guideline developed by the American Cancer Society, US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology as well as the USMSTF on Colorectal Cancer recommends that individuals at average risk for the development of colorectal cancer begin screening at 50 years of age (Levin, 2008, Rex, 2017). Similarly, the National Comprehensive Cancer Network (NCCN) guidelines on colorectal cancer screening recommend that colorectal cancer screening of average-risk individuals begin at age 45 years (NCCN, 2021).
In 2018, the American Cancer Society (ACS) included several recommendations regarding colorectal cancer screening. For individuals at average risk, the society issued a “strong recommendation” that screening being at age 50 using one of several screening techniques: colonoscopy, sigmoidoscopy, CT colonography, multi-target stool DNA testing, fecal immunochemical testing or high-sensitivity guaiac-based stool testing. The “strong recommendation” signifies that “benefits of adherence to the intervention outweigh the undesirable effects and that most patients would choose the intervention”. The society also recommended that individuals considered to be at average risk for colorectal cancer should begin screening at age 45 years. However, this was a “qualified recommendation” indicating that “there is clear evidence of benefit (or harm) but less certainty either about the balance of benefits and harms or about patients’ values and preferences, which could lead to different individual decisions”. In support of its “qualified recommendation”, the ACS cites SEER (Surveillance, Epidemiology, and End Results) data which demonstrated a 22% relative increase (from 5.9 to 7.2 cases per 100,000 person-years) in the incidence of colorectal cancer between 2000 and 2013 for individuals between 40 to 49 years of age. However, other factors such as environmental influences, including but not limited to diet, and rising obesity rates, may have played a part in the increase in colorectal cancer in individuals between 45 to 49 years of age. Also, while it may be reasonable to assume that screening individuals younger than the age of 50 will produce similar results as screening individuals older than 50 years of age for colorectal cancer, the ACS recommendations did not provide any direct evidence of this assertion. Instead, the ACS recommendations were based on modeling studies on the natural history of colorectal neoplasia and the performance of colorectal screening. The authors of the ACS guidelines acknowledge that some assumptions must be made in order for the guidelines to improve population health. Some of these assumptions are that screening tests are as effective in younger individuals as in older individuals, that there will be 100% adherence to the screening recommendations (Wolf, 2018).
In response the to 2018 ACS recommendation that colorectal cancer (CRC) screening be initiated in average risk individuals beginning at age 45 years, the USMSTF released an updated statement on colorectal cancer screening. In the updated statement the USMSTF maintained its position that colorectal cancer screening for average-risk persons begin at age 45 years in African Americans and at age 50 years in other groups. In support of these recommendations, the USMSTF also stated that:
Evidence from screening studies to support lowering the screening age is very limited at this time. Based on the modeling study used to support the ACS recommendation, the MSTF recognizes that lowering the screening age to 45 may improve early detection and prevention of CRC. The MSTF expects the new ACS recommendation to stimulate investigation that will clarify the benefits and risks of earlier screening.
As the MSTF has previously noted and discussed, rates of colorectal cancer are increasing in Americans down to age 20 years. Beginning screening at 45 years addresses only part of the increasing risk of colorectal cancer in young persons. For all persons under 50 years, it remains critical to promptly assess symptoms consistent with colorectal cancer. In particular, rectal bleeding and unexplained iron deficiency anemia have substantial predictive value for colorectal cancer and should be thoroughly evaluated (USMSTF 2018)
The United States Preventive Services Task Force (USPSTF, 2021) guidelines on screening for colorectal cancer are unique in that they provide age-based guidance on when routine colonoscopy screening should be initiated and terminated. The updated USPSTF recommendations state that screening colonoscopy begin at age 45 years and continue to age 75 years. This is a change from the prior version, which indicated the lower threshold for screening colonoscopy as 50 years of age. The update is based on emerging evidence that colorectal cancer cases in persons younger than age 50 years have been slowly increasing (for reasons that are not entirely understood). According to the USPSTF, the number of individuals diagnosed with colorectal cancer at age 45 years today is similar to the number of individuals diagnosed with colorectal cancer at age 50 years in 1992. As part of the USPSTF review, an updated modelling study was commissioned to explore the benefits and harms of colorectal cancer screening in adults younger than 50 years. According to the analysis, lowering the age of screening from 50 to 45 years results in approximately 2 to 3 additional cases and 1 additional death due to colorectal cancer being averted per 1,000 adults screened. The harms of screening, generally resulting from colonoscopy (such as bleeding and bowel perforation), either as the screening test or as follow-up for positive findings detected by other screening tests, have not been carefully evaluated in younger individuals, but are estimated by the USPSTF to be “small”. For individuals 76 to 85 years of age, the USPSTF concluded that the benefits of screening for colorectal cancer diminish while the risk of experiencing serious associated harms increase. Therefore, the decision to screen for colorectal cancer in individuals between 76 and 85 years of age “should be an individual one, taking into account the patient’s overall health and prior screening history”. For this group, the USPSTF has indicated that “screening would be most appropriate among adults who (1) are healthy enough to undergo treatment if colorectal cancer is detected and (2) do not have comorbid conditions that would significantly limit their life expectancy”. The USPSTF recommends against the use of colorectal cancer screening in adults 85 years of age or older (USPSTF, 2016).
Colonoscopy is considered the gold standard for colon cancer surveillance. Surveillance intervals (which provide guidance on how frequently a colonoscopy should be repeated), are based upon the individual's risk factors (for example, the individual’s personal medical history, family history of colorectal cancer and the results of earlier colonoscopies). Surveillance with earlier and more frequent colonoscopy is recommended for individuals who are at increased risk for colorectal cancer.
Due to advances in next-generation sequencing (NGS) technology, multigene tests which simultaneously analyze a set of genes that are associated with a specific family cancer phenotype or multiple phenotypes are being explored as a means to create colonoscopy surveillance recommendations. With regards to using multigene testing to develop colonoscopy surveillance recommendations, the NCCN has indicated it “recognizes that data to support the surveillance recommendations for these particular genes are evolving at this time” and that “caution should be used when implementing final colonoscopy surveillance regimens in context of patient preferences and new knowledge that may emerge” (NCCN, Genetic/Familial High-Risk Assessment Colorectal, 2023).
References |
Index |
Colonoscopy
Colorectal Cancer Screening
History |
Status | Date | Action |
|
Revised | 08/10/2023 | Medical Policy & Technology Assessment Committee (MPTAC) review. Revised MN criteria section A - Screening Colonoscopy in Average Risk Populations to include individuals with no personal history of cystic fibrosis. Revised MN criteria section B - Surveillance Colonoscopy in At-Risk Populations to include criteria for individuals with personal history of cystic fibrosis and individuals at increased risk based on personal history of childhood, adolescent and young adult cancer. Revised MN criteria section C- Screening Colonoscopy in Higher Risk Populations bullet #1 Family History of Colorectal Cancer or Adenomas to consider colonoscopy MN in a first degree relative (parent, sibling or child) with colorectal cancer diagnosed at any age and for one second and third-degree relative with colorectal cancer at any age. Updated Discussion/General Information and References sections. Revised formatting throughout document. | |
Revised | 08/11/2022 | MPTAC review. In medically necessary criteria for Surveillance Colonoscopy in At-Risk Populations: (1) revised bullets # 3-b-1 and #3-c in section on adenomatous polyps or SSP; (2) revised criteria for inflammatory bowel disease by adding bullet #6-a-iii. In section on Diagnostic Colonoscopy, added medically necessary criteria for individuals with a history of diverticulitis. Also updated the parenthetical numbering following each criterion, as needed. Updated References and History sections. | |
Reviewed | 08/12/2021 | MPTAC review. In the Clinical Indications section, updated the parenthetical numbering following each criterion, as needed. Updated References and History sections. Updated Coding section to add CPT codes 44388, 44389, 44390, 44391, 44392, 44391, 44401, 44402, 44403, 44404, 44405. | |
Revised | 05/25/2021 | MPTAC review. Updated MN statement to revise age for beginning colonoscopy to detect colorectal cancer and adenomatous polyps from 50 to 45. Removed note from MN section. Updated Discussion and References sections. | |
Revised | 08/13/2020 | MPTAC review. In the Clinical Indications section, revised criteria in section C1 (Screening Colonoscopy in Higher Risk Populations on Screening Colonoscopy in Higher Risk Populations, Family History of Colorectal Cancer or Adenomas). Updated References and History sections. Reformatted Coding section. | |
Reviewed | 08/22/2019 | MPTAC review. Updated the Description, Discussion/General Information and References sections. | |
Reviewed | 03/21/2019 | MPTAC review. Updated the References and History sections. | |
Revised | 07/26/2018 | MPTAC review. In Clinical Indications section, updated the parenthetical numbering following each criterion, as needed. Updated the Discussion/General Information, References and History sections. | |
| 05/03/2018 | The document header wording updated from “Current Effective Date” to “Publish Date.” | |
Reviewed | 08/03/2017 | MPTAC review. Minor format changes to Clinical Indications section. Updated Discussion/General Information, References and History sections. Updated Coding section to remove G6024, G6025 deleted 12/31/2015. | |
Revised | 05/04/2017 | MPTAC review. In the Medically Necessary position statement, bullet A3 was revised to indicate that for individuals at average risk, if prior CRC screening was conducted using Cologuard and the results were negative, then the next re-screening may be performed using colonoscopy in 3 years. Minor language and/or formatting changes in sections A and B of the Medically Necessary criteria. Updated the Discussion/General Information, References and History sections. | |
Revised | 05/05/2016 | MPTAC review. Revised the following sections of the Medically Necessary criteria: (1) Screening Colonoscopy in Average Risk Populations; (2) Surveillance Colonoscopy in At-Risk Populations – Adenomatous Polyps; (3) Surveillance Colonoscopy in At-Risk Populations – Inflammatory Bowel Disease (chronic ulcerative colitis or Crohn's colitis) and related conditions; (4) Screening Colonoscopy in Higher Risk Populations - Family History of Colorectal Cancer or Adenomas; (5) Diagnostic Colonoscopy and (6) Therapeutic Colonoscopy. Also, as appropriate, throughout the document, revised statements with an age range to include the phrase “no less than” and removed the word “should” from the document. Updated the References and History sections. Removed ICD-9 codes from Coding section. | |
Revised | 05/07/2015 | MPTAC review. Revisions include but are not limited to the following: Criteria divided into 5 general categories: (1) Screening -Average Risk; (2) Screening-Higher Risk; (3) Surveillance – At Risk; (4) Diagnostic; and (5) Therapeutic Colonoscopy. Section A Screening Colonoscopy - Average Risk Populations: Clarified that medically necessary criteria for average risk individuals includes sessile serrated polyps (SSPs). Added criteria for colonoscopy based on a stool based test. Removed the words “left-sided” from the criterion for individual with a personal history of hyperplastic, non-SSP less than 1 cm removed at colonoscopy. Section B Surveillance Colonoscopy - At Risk Populations revised to address individuals with a personal history of a positive stool based test. Clarified that the medically necessary criteria for adenomatous polyps includes sessile serrated polyps (SSPs). Moved a portion of the medically necessary criteria addressing serrated polyposis syndrome and a portion of criteria addressing colonic adenomatous polyposis of unknown etiology to Section B Surveillance Colonoscopy - At Risk (criteria was unchanged). Revised and moved medically necessary criteria for Inflammatory Bowel Disease to Section B Surveillance Colonoscopy-At Risk section. Section C Screening Colonoscopy in Higher Risk Populations: Revised medically necessary criteria addressing family history of colorectal cancer or adenomas and the medically necessary criteria for Lynch Syndrome. In the Not Medically Necessary section, clarified this section includes surveillance colonoscopy. Updated Description, Discussion and Reference sections. | |
| 01/21/2015 | Updated Coding section with 01/01/2015 CPT and HCPCS changes; removed 45383, 45387 deleted 12/31/2014. | |
Revised | 05/15/2014 | MPTAC review. Expanded criteria for screening colonoscopy in average risk individuals to include those with history of hyperplastic, right-sided non-SSP. In section on screening colonoscopy in higher risk individuals, revised criteria for the following: (1) adenomatous polyps; (2) family history of colorectal cancer or adenoma and (3) inflammatory bowel disease. Added new medically necessary criteria for colonic adenomatous polyposis of unknown etiology. | |
Revised | 05/09/2013 | MPTAC review. Expanded medically necessary criteria to address: (1) Individuals with personal history of hyperplastic, left-sided, non-SSP; (2) Individuals with a family history of CRC or adenomas and (3) serrated polyposis syndrome (SPS). Inserted or deleted “and” or “or” in the criteria as needed to provide clarity. Updated review date and References. | |
Revised | 05/10/2012 | MPTAC review. Expanded medically necessary criteria for individuals with FAP to include annual colonoscopy beginning at ages 10-12 years. Updated review date, References and History sections. | |
Reviewed | 05/19/2011 | MPTAC review. Updated review date, References and History sections. | |
Revised | 05/13/2010 | MPTAC review. Criteria updated based on the National Comprehensive Cancer Network. Guidelines on Colorectal Cancer Screening V1.2010 and the 2010 American Gastroenterological Association (AGA) Position Paper on Screening Patients with Inflammatory Bowel Disease (IBD) for Colorectal Cancer. Updated review date, References and History sections. | |
Reinstated | 02/25/2010 | MPTAC review. Reinstated document which was archived on November 19, 2009. Grammatical and typographical corrections made to clinical indications. | |
Historic | 11/19/2009 | Not to be used for dates of service on or after 11/19/2009. | |
Reviewed | 05/21/2009 | MPTAC review. Added references to the following guidelines and noted where they were applicable in the patient selection criteria: (1) American College of Gastroenterology guidelines for colorectal cancer screening (2008); (2) National Comprehensive Cancer Network. Colorectal Cancer Screening V1.2009; (3) US Preventive Services Task Force. Screening for colorectal cancer (2008). Also, in the patient selection criteria for FAP, added information to the “Note” to clarify that MYH-associated is the same as attenuated FAP. Minor formatting changes. No substantive change to patient selection criteria. Updated review date, description, discussion/general information and history sections. | |
Revised | 05/15/2008 | MPTAC review. Revised the patient selection criteria to reflect the recommendations made in the Screening and Surveillance for the Early Detection of Colorectal Cancer and Adenomatous Polyps, 2008: A Joint Guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. Updated review date, rationale and references sections. | |
Reviewed | 05/17/2007 | MPTAC review. Updated references, coding, and review date. | |
Revised | 06/08/2006 | MPTAC revision. For clinical indication, Family History of Colorectal Cancer or Adenoma, criteria updated to two or more first-degree relatives. | |
Reviewed | 03/23/2006 | MPTAC annual review. References updated. | |
| 11/17/2005 | Added reference for Centers for Medicare & Medicaid Services (CMS) -National Coverage Determination (NCD). | |
Revised | 04/28/2005 | MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization. |
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Pre-Merger Organizations | Last Review Date | Document Number | Title |
Anthem BCBS | 08/12/2004 | UMR.003 | Colorectal Cancer Screening |
WellPoint Health Networks, Inc. | 12/02/2004 | Clinical Guideline | Colonoscopy |
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